Counseling & Psychological Services
Consent for Direct Observation, Audio and/or Visual Recording, and/or Co-therapy
RIT’s Counseling & Psychological Services (CPS) serves as a training site for graduate
students completing training to earn a master’s or doctoral degree in social work, mental health
counseling, or psychology. Trainees working at CPS are supervised by highly competent,
licensed clinicians and staff members. To provide the highest quality supervision, supervisors
require trainees to provide access to all clinical work enacted by trainees. This access may
include, but is not limited to, supervisor direct observation of sessions, audio and/or visual
recording of sessions, and supervisor engagement in co-therapy sessions.
 The individual(s) responsible (i.e., therapist name printed below) for maintaining the
security and confidentiality of any recorded material or information obtained through
observation will make reasonable efforts to ensure their security and confidentiality.
 Recorded material and information obtained through direct observations and co-therapy
sessions will be shared only with CPS staff and/or supervisors and/or with supervisors
within the trainee’s graduate program.
 Your full name will not appear on recorded materials.
 All material/information obtained will be used solely for training and educational
purposes, with the viewing focus on the trainee him/herself in an effort to evaluate his/her
skills as a professional.
 All recorded material will be destroyed upon your therapist’s completion of the RIT CPS
Training Program.
I have read and discussed the above information with my therapist and hereby give my
consent to allow direct supervisory observation of sessions, audio and/or visual recording of
sessions, and/or co-therapy sessions with my therapist’s supervisor(s).
Client Name (Print): ________________________________________________________
Client Signature:_______________________________________ Date:________________
Therapist Name (Print): ______________________________________________________
Therapist Signature: ____________________________________ Date: _______________